Introduction to Implementation Research on Addictions
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1 Introduction to Implementation Research on Addictions Kathy Bradley, MD, MPH Senior Investigator GHRI Affiliate Professor Medicine and Health Services, University of Washington Research Associate VA Puget Sound HSR&D 1
2 Outline 1. What is implementation research? Overview Example Lessons learned 2. Introduction to conceptual models Greenhalgh Other models Patient- and user-centered design 3. Training and tools 2
3 Research Pipeline Mark Bauer
4 Implementation Research Efficacy Trials Effectiveness Trials Implementation Trials Internal validity External validity In the real world Select sample Detailed inclusions/exclusions Few exclusions Real world sample No exclusions for research reasons Research clinic Real-world clinic Interventionist hired by study Care per protocol Interventionist trained as in clinical setting Trained as in the real world Routine clinical staff provide care Clinicians in health system Trained +++ patient time Minimize research time 0-small research time Many outcomes (often pay subjects) Few select outcomes Outcomes as in clinical care (don t pay subjects) 4
5 Implementation SCIENCE the scientific study of methods to promote the systematic uptake of research findings into routine practice -Eccles & Mittman, Implementation Science, 2006 (Mark Bauer )
6 Case Study Implementation Research 6
7 SBI in VA Nationwide 1. Screening and Brief Alcohol Interventions (SBI) 2. Initiated by QI leaders
8 VA Health Care System
9 SBI in VA Nationwide 1. Initiated by QI leaders 2. Performance measures Screening 2004 BI EHR tools
10 EHR Clinical Decision Support Provider Education Assessment & Risk Stratification Decision Support & Education Options for Patient Feedback and Further Assessment Documentation in progress note
11 SBI in VA Nationwide 1. Initiated by QI leaders 2. Performance measures 3. EHR tools 4. Training materials available
12 SBI in VA Nationwide 1. Screening rates: 95% immediately 2. BI increased slowly but reached 76% 3. Evaluation using clinical data Bradley Am J Manag Care 2006; Lapham Medical Care 2012 Bradley Addiction 2011
13 Some Things Didn t Not Go as Planned 13
14 SBI in VA Nationwide 1. Prevalence of positive screens Low prevalence: Patient survey ~25% EHR ~ 11-16% Decreasing over time: 16% to 4-9% Bradley Am J Manag Care 2006
15 SBI in VA Nationwide Documented BI Among Screen-positive Patients * * Rates are from VA s National Performance Measure Reporting System 12 (Chavez, JSAD, in press)
16 Patient-reported Advice Among screen positive patients Adjusted for age, gender, race/ethnicity, education, smoking status (Chavez, JSAD, 2016)
17 SBI in VA Nationwide 1. Documented advice higher than patient report? 2. Reward sites who identified fewer patients? Bradley Psych Services 2013; Lapham DAD 2014
18 Greenhalgh Model: Designing Implementation Strategies 18
19 Greenhalgh Model
20 Innovators Support: Financial, Technical & Clinical (Resources) Researchers - Content Experts (Knowledge Purveyors) Dissemination Quality Improvement (Change Agents) LINKAGE The Innovation LINKAGE Diffusion User System Health System (System Antecedents) Pressures for Change (System Readiness) Managers & Clinicians (adopters/assimilation) Implementation Consequences Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
21 Innovators Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
22 Innovators Resources Support: Financial & Technical Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
23 Innovators Resources Support: Financial & Technical Experts Researchers - Content Experts Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
24 Innovators Resources Support: Financial & Technical Experts Researchers - Content Experts Change Agents Operations Congress Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
25 Innovators Resources Support: Financial, Technical & Clinical LINKAGE User System Experts Researchers - Content Experts Change Agents Operations Congress LINKAGE Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
26 Innovators Resources Support: Financial, Technical & Clinical LINKAGE User System System Antecedents VA System Experts Researchers - Content Experts Change Agents Operations Congress LINKAGE Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
27 Innovators Resources Support: Financial, Technical & Clinical Experts Researchers - Content Experts LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Change Agents Operations Congress LINKAGE Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
28 Innovators Resources Support: Financial, Technical & Clinical Experts Researchers - Content Experts LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Change Agents Operations Congress LINKAGE Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
29 Implementation research is a team sport Dan Kivlahan
30 Innovators Knowledge Purveyors Researchers - Content Experts LINKAGE Resources Support: Financial, Technical & Clinical The Innovations Change Agents Operations Congress Diffusion Dissemination LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Adopters/Assimilation Managers & Clinicians Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
31 Innovators Resources Support: Financial, Technical & Clinical Knowledge Purveyors Researchers - Content Experts Change Agents Change Agents Operations Congress LINKAGE The Innovations Diffusion Dissemination LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Adopters/Assimilation Managers & Clinicians Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
32 Passive Implementation of BI We neglected adopters
33 Adopter Attitudes 1. National webinar for quality managers Screening BI 2. After the second 33
34 Adopter Attitudes She s Crazy 34
35 from PCP re EHR Tools SMALL PRINT: ALSO THE BRIDGE IS OUT AHEAD
36 Innovators Resources Support: Financial, Technical & Clinical Knowledge Purveyors Researchers - Content Experts Change Agents Office of Quality & Performance LINKAGE The Innovations Diffusion Dissemination LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Adopters/Assimilation Managers & Clinicians Implementation Consequences Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
37 Innovators Resources Support: Financial, Technical & Clinical Knowledge Purveyors Researchers - Content Experts Change Agents Office of Quality & Performance LINKAGE The Innovations Diffusion Dissemination LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Adopters/Assimilation Managers & Clinicians Implementation Consequences Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009
38 Innovators Resources Support: Financial, Technical & Clinical Knowledge Purveyors Researchers - Content Experts Change Agents Office of Quality & Performance LINKAGE The Innovations Diffusion Dissemination LINKAGE User System System Antecedents VA System System Readiness Pressures for Change Adopters/Assimilation Managers & Clinicians Implementation Consequences Greenhalgh T et al, Milbank Quarterly. 2004;82: Bradley KA & Williams EC, Principles of Addiction Medicine, 2009, 2013
39 Other Implementation Research Conceptual Models 39
40 Other Conceptual Models for Implementation Research 1. RE-AIM Glasgow 2. PRISM Feldstein and Glasgow 3. UCLA/RAND/NIMH model Mendel 4. CFIR - Damschroder 5. Hybrid Effectiveness-Implementation Trials Curran Hybrid Type 1 Mostly effectiveness Hybrid Type 2 Hybrid Type 3 Mostly implementation Glasgow, Implement Sci 2011 Feldstein Jt Comm J Qual Patient Saf 2008 Mendel, Adm Policy Ment Health Damschroder, L. J., Implement Sci Curran MedCare
41 RE-AIM Reach % patients reached Effectiveness Impact of implementation on outcomes Adoption % providers ( agents ) or clinics who adopt Implementation fidelity evidence-based practices? Maintenance sustained after research left? Glasgow Patient Educ Counseling 2001; Glasgow and Chambers Clin Trans Science
42 PRISM 1. RE-AIM plus 2. Simple yet complete 3. Good for grants Feldstein Ann Fam Med
43 Sustained Patient-centered Alcohol-Related Care (SPARC Trial) AHRQ R18 43
44 Ideal Alcohol-related Primary Care Monitor and Adapt Screen Shared decision making & treatment Assess 44
45 Implementation in Group Health
46 Goal: Improve the Quality of Behavioral Health Care When I had my knees replaced my doctor gave me a video & booklet and sent me to talks at the hospitals. Then, we talked about the option that seemed best for me When I sought help for my addictions he just gave me a phone # GH patient 46
47 Overview SPARC Project Duration: months Preparation Pragmatic Trial of Alcohol SBI and Shared Decision-Making for Alcohol Use Disorders Pilot 3 clinics Pilot Wave 1 3 clinics 1 Wave 2 3 clinics 2 Wave 3 3 clinics 3 Wave clinics 4 Wave clinics 5 Wave clinics 6 47
48 Overview SPARC Project Duration: months Preparation Pragmatic Trial of Alcohol SBI and Shared Decision-Making for Alcohol Use Disorders Pilot 3 clinics Pilot Wave 1 3 clinics 1 Wave 2 3 clinics 2 Wave 3 3 clinics 3 Wave clinics 4 Wave clinics 5 Wave clinics 6 48
49 Overview SPARC Project Duration: months Preparation Pragmatic Trial of Alcohol SBI and Shared Decision-Making for Alcohol Use Disorders Pilot 3 clinics Pilot Wave 1 3 clinics 1 Wave 2 3 clinics 2 Wave 3 3 clinics 3 Wave clinics 4 Wave clinics 5 Wave clinics 6 49
50 Overview SPARC Project Duration: months Preparation Pragmatic Trial of Alcohol SBI and Shared Decision-Making for Alcohol Use Disorders Pilot 3 clinics Pilot Wave 1 3 clinics 1 Wave 2 3 clinics 2 Wave 3 3 clinics 3 Wave clinics 4 Wave clinics 5 Wave clinics 6 50
51 User Centered Design 51
52 User Centered Design Johnson J Biomed Inform 2005 Zhang J Biomed Inform
53 Part 4 Trainings and Tools 53
54 Trainings and Tools 1. Implementation research institute (IRI): 2. Society for Implementation Research Collaboration: on.org/ 3. VA Quality Enhancement Research Initiative: 4. Prevention science and Methodology group: 5. NIH Research: ination_and_implementation/index.aspx s-research-and-epidemiology-branch/dissemination-andimplementation-research-program.shtml 6. Dartmouth Microsystems Training 54
55 Funding Implementation Research
56 Acknowledgements NIAAA K24 - AA NIDA CTN: UG1 - DA CTN #0065 AHRQ R18 HS Small grants
57 Thank You! (References on Coversheet) 57
58 Questions? 58
59 UCLA/RAND/NIMH Model Processes: Stage 1: Capacity & needs assessment Stage 2: Implementation & process evaluation Stage 3: Outcome & impact evaluation Mendel Adm Policy Mental Health 2008
60 UCLA/RAND/NIMH Model Contextual Factors 1. Norms and attitudes 2. Organizational structure and process 3. Resources 4. Policies & incentives 5. Networks and linkages 6. Media and change agents Mendel Adm Policy Mental Health 2008
61 UCLA/RAND/NIMH Model Stages of Diffusion 1. Adoption 2. Implementation 3. Sustainability Mendel Adm Policy Mental Health 2008
62 UCLA/RAND/NIMH Model Intervention Outcomes 1. Individual level Process Health status 2. Organization and system level Service priorities Reorganization New policies or collaborations Mendel Adm Policy Mental Health 2008
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